HsSjjJjr 

f 


w*r? 


A'- 


UNIVERSITY  BULLETIN 

NEW  SERIES,  VOL.  XXIII,  NO.  20.  NOVEMBER  12,  1921. 


UNIVERSITY  OF  MICHIGAN 


SOME  PROBLEMS  IN  MEDICAL  EDUCATION 
AS  THEY  CONCERN  THE 
UNIVERSITY  OF  MICHIGAN 


HUGH  CABOT 


ANN  ARBOR 

PUBLISHED  BY  THE  UNIVERSITY 


SOME  PROBLEMS  IN  MEDICAL  EDUCATION 
AS  THEY  CONCERN  THE 
UNIVERSITY  OF  MICHIGAN 


THE  ADDRESS  OF  THE  DEAN 
AT  THE  OPENING  OF  THE  MEDICAL  SCHOOL 
ON 

SEPTEMBER  27,  1921. 


Digitized  by  the  Internet  Archive 
in  2017  with  funding  from 

University  of  Illinois  Urbana-Champaign  Alternates 


https://archive.org/details/someproblemsinmeOOcabo 


ADDRESS  OF  THE  DEAN  AT  THE  OPENING  OF  THE 
MEDICAL  SCHOOL 


C 

/VI 5%  u 

ho  .ftiO 


I find  myself  this  morning  in  a difficult  position.  Difficult  for  two 
reasons,  firstly,  because  I am  taking  up  the  reins  laid  down  by  a great 
man  and  secondly,  because  this  is  a time  when  many  problems  in  the 
teaching  of  medicine  press  for  solution.  There  is  perhaps  more  change 
in  the  air  than  is  ordinarily  the  case.  In  regard  to  the  latter  difficulty, 
one  should  perhaps  not  complain  since  it  adds  zest  and  interest  to  life 
and  we  may  be  sure  that  no  monotony  or  drabness  will  surround  the 
next  few  years  of  medical  teaching.  In  regard  to  my  first  difficulty,  the 
case  is  far  otherwise.  To  classify  Dr.  Vaughan  as  a great  man  is  no  idle 
compliment  and  the  doubtful  have  merely  to  look  at  the  monument  he 
has  left  here  for  their  answer.  Many  would  perhaps  be  glad  to  be  judged 
by  their  intentions,  but  in  the  long  run,  the  world  will  probably  judge 
us  by  our  results  and  it  is  reasonable  that  we  should  judge  Dr.  Vaughan 
by  his  results.  He  came  here  in  the  early  days  of  organized  medical 
teaching  in  this  country.  More  than  thirty  years  ago,  he  became  the 
executive  officer  in  this  Medical  School  and  it  is  strictly  accurate  to  say 
that  this  school  is  his  monument.  Its  policies  have  been  worked  out,  its 
faculty  has  been  brought  together  and  stand  as  the  result  of  his 
extraordinary  executive  capacity. 

In  the  days  when  it  became  his  duty  to  decide,  it  required  not  only 
foresight  in  decision  but  unusual  boldness  to  undertake  the  building  up  of 
a great  medical  school  without  the  facilities  of  a large  city.  No  such 
schools  existed  or  to  the  best  of  my  knowledge  ever  had  existed,  and 
the  soundness  of  the  proposition  that  a medical  school  giving  complete 
instruction  in  all  branches,  both  pre-clinical  and  clinical,  could  be  built 
up  in  a city  of  less  than  ten  thousand  inhabitants  might  reasonably  be 
doubted-  As  a relatively  new  comer  here,  I can  without  bias  estimate 
the  position  of  this  school  in  relation  to  the  other  schools  of  the  country 
and  I can  say  without  hesitation  that  it  stands  in  first  rank,  that  it 
has  always  stood  high  in  the  character  of  its  pre-clinical  instruction  and 
that,  with  the  up-building  of  the  University  Hospital,  it  has  stood  high 
in  the  character  of  its  clinical  instruction.  The  decision  made  under 
his  administration  to  retain  the  clinical  teaching  in  Ann  Arbor  rather 
than  to  allow  it  to  be  transferred  to  Detroit  is  evidence  of  great  wisdom 
and  great  fore-sight.  Today  discussions  concerning  the  possibility  of 
building  up  clinical  departments  in  small  cities  are  being  answered  the 


— 4 — 


country  over  by  pointing  to  the  example  of  the  University  of  Michigan. 
It  means  that  the  policy  laid  down  by  Dr.  Vaughan  has  been  a convincing 
success. 

The  character  and  standing  of  this  faculty  must  be  a lasting 
monument  to  him  as  a judge  of  men.  All  obstacles  which  have  here 
been  overcome,  particularly  in  regard  to  the  teaching  of  clinical  branches 
are  a lasting  monument  to  his  judgment  and  pre- vision.  We  may  properly 
regard  him  as  one  of  the  greatest  medical  educators  that  this  country 
has  ever  produced  and  we  may  fairly  doubt  whether  we  shall  be  able 
to  direct  the  policy  of  this  school  with  equal  judgment. 

It  is  however  proper  at  this  time  that  I should  state  as  clearly  and 
as  frankly  as  possible  the  fundamental  objects  which  I believe  to  be 
comprehended  under  the  term  “policy”  of  this  school.  A medical  school 
today  may  be  thought  of  as  having  three  teaching  functions  and  presenting 
three  ideals  and  facets  to  the  world: 

1.  The  teaching  of  undergraduates. 

2.  The  teaching  of  graduate  physicians  and  the  advancement  of  the 
boundaries  of  medical  knowledge. 

3.  The  teaching  of  the  public  in  matters  of  public  health  and 
health  policy  and  assisting  in  working  out  the  relation  of  physicians  and 
hospitals  to  the  people  of  the  state. 

1.  POLICY  IN  REGARD  to  TEACHING  OE  UNDERGRADUATES. 

I may  say  at  once  that  unless  I gravely  mistake  the  temper  of 
this  faculty  no  fundamental  change  is  contemplated.  Clearly  the  most 
debatable  and  debated  question  is  that  of  so  called  “full  time”  instruction 
in  the  clinical  branches.  Here  no  change  of  policy  is  contemplated 
since  it  is  more  than  two  years  since  this  faculty  voted  its  approval 
of  the  theory  involved.  This  is  not  the  time  nor  the  place  to  re-state 
the  argument  concerning  full  time  teaching  but  it  is  proper  that  our 
position  should  be  made  clear  at  the  outset. 

The  theory  of  full  time  teaching  in  the  clinical  branches  is  relatively 
simple  and  concerning  it  there  is  little  difference  of  opinion.  That  it 
is  a desirable  method,  most  will  agree  and  this  agreement  has  come  from 
the  clear  demonstration  of  the  unsatisfactory  character  of  part  time 
teaching  in  these  branches.  It  will  be  generally  admitted  that  part 
time  teaching  involves  a dual  allegiance,  one  to  the  university  and  one 
to  the  individual  himself  and  this  divided  allegiance  has  resulted  in 
teaching  somewhat  less  than  satisfactory.  That  the  difficulty  is  widely 


— 5— 


recognized  and  generally  admitted  is  clear  since  most  of  the  great 
medical  schools  in  the  country  are  experimenting  with  such  full  time 
teaching  in  some  form. 

But,  it  is  not  over  the  theory  of  full  time  instruction  but  over 
the  practice  that  doubt  and  difficulty  has  arisen.  It  is  undoubtedly  true 
that  today  there  is  no  well  demonstrated  plan  of  full  time  teaching  in 
clinical  branches  which  is  regarded  as  satisfactory  by  a large  number 
of  those  competent  to  an  opinion.  Discussions  of  the  matter  have  been 
considerably  impeded  by  the  failure  to  draw  a distinction  between  the 
application  of  this  principle  to  medical  schools  situated  in  large  cities 
and  its  application  to  those  situated,  as  we  are,  in  small  cities.  But 
the  difference  is  very  real  and  cannot  be  omitted  from  any  discussion 
without  seriously  compromising  the  soundness  of  the  conclusion.  The 
employment  of  part  time  teachers  for  all  the  clinical  branches  is  a 
relatively  simple  matter  and  comparatively  more  satisfactory  in  those 
schools  situated  in  large  cities  with  quantities  of  clinical  material  at  hand. 
If,  however,  part  time  teaching  has  been  unsatisfactory  in  the  group 
just  referred  to,  it  has  been  far  more  unsatisfactory  here.  The  teacher 
must  here  stretch  himself  thinner  and  thinner  over  the  field  he  is 
required  to  cover  and  may  in  the  end  fail  to  achieve  success  either  as 
a teacher  or  as  a practitioner  of  medicine.  Thus,  clearly  the  problem 
is  one  of  paramount  importance  and  we  must  bring  to  it  our  best 
judgment  applied  always  with  patience  and  respect. 

It  is  my  own  well  considered  opinion  that  full  time  instruction  in 
clinical  subjects  will  not  achieve  its  best  results  if  the  character  of  the 
instruction  is  essentially  altered  from  that  given  in  the  past  by  the 
schools  employing  part  time  services.  If  as  the  result  of  full  time 
teaching,  we  are  to  see  it  fall  into  the  hands  of  those  who  are  essentially 
scientists  unfamiliar  with  the  art  of  medicine,  I shall  be  unwilling  to 
admit  that  we  are  doing  our  full  duty  to  the  student.  We  must,  I believe, 
continue  to  attract  to  these  teaching  positions  men  of  experience  both 
in  the  science  and  in  the  art  of  medicine.  If  this  premise  be  admitted, 
it  follows  necessarily  that  the  most  difficult  question  is  one  of  financing. 
We  shall  require  men  who  have  achieved  distinction  and  are  able  to 
command  relatively  large  incomes-  That  the  Medical  School  can  properly 
afford  to  offer  them  salaries  equal  to  their  earning  capacity  as  practitioners, 
I do  not  believe,  but  it  must  be  prepared  to  offer  them  something 
approaching  their  market  value  or  in  the  long  run  they  will  not  come. 

As  I have  already  intimated  there  is  no  general  agreement  as  to 
how  the  principle  of  full  time  teaching  shall  be  put  into  practice.  Many 


— 6 — 


methods  are  being  tried.  Some  of  them  are  far  reaching  and  some  of 
them  are  very  moderate  and  hesitating.  The  fact  of  the  matter  is 
that  there  is  no  body  of  experience  entitling  anyone  to  pass  final  judgment 
in  this  matter.  All  are  experimenting  and  the  more  methods  that  are 
tried  in  good  faith,  the  sooner  we  shall  be  able  to  accumulate  a body 
of  fact  entitling  to  an  opinion. 

But  if  we  are  to  experiment  we  must  try  the  method  in  a reasonable 
way  such  that  our  conclusions  will  be  entitled  to  weight.  Enough 
departments  must  be  put  on  full  time  to  allow  drawing  of  sound 
inferences  and  at  the  same  time  the  school  must  not  so  far  commit 
itself  as  to  lose  its  flexibility  and  be  unable  to  adapt  itself  to  reasonable 
changing  conditions.  It  would  indeed  be  a bold  man  who  would  assert 
that  he  was  sure  of  the  best  method  to  utilize  “full  time”  in  the  clinical 
branches.  In  working  out  this  experiment  on  the  basis  which  I have 
stated,  it  is  essential  that  the  university  should  respect  its  commitments 
and  no  agreements  expressed  or  implied  can  properly  be  disregarded. 
Futhermore,  we  must  at  all  times  keep  our  minds  open  and  preserve  a 
decent  respect  for  the  opinions  of  others. 

On  the  other  hand  however,  this  experiment  is  entitled  to  an  honest 
trial.  Here  we  have  elected  a method  whereby  the  whole  weight  of 
financing  this  work  does  not  fall  upon  the  tax  payer  but  is  borne  in 
part  by  the  legitimate  income  of  the  hospital.  It  is  my  judgment  that 
by  distributing  the  burden  in  this  way,  it  will  not  bear  too  heavily 
upon  the  school  and  is  far  more  likely  to  succeed  than  any  other  yet 
attempted  method. 

I do  not  need  to  remind  you  that  the  plan  has  been  much  criticised 
but  most  of  the  critics  have  not  faced  the  problem  and  offered  no  solution 
unless  it  be  that  we  should  ask  the  tax  payer  to  assume  the  whole  burden 
which  suggests  that  they  really  desire  failure  and  regard  this  as  a most 
convenient  method  of  getting  it.  There  has  been  much  loose  talk  about 
the  state’s  interference  in  the  practice  of  medicine,  apparently  in  entire 
disregard  of  the  fact  that  the  state  has  been  gradually  insinuating  itself 
into  the  practice  of  medicine  for  two  generations.  It  has  been  alleged 
that  the  competition  thus  introduced  is  unfair  when  as  it  seems  to  me, 
it  is  far  less  so  than  under  the  system  of  part  time  when  with  all  the 
advantages  which  accrue  from  a university  connection,  the  clinical  staff  still 
competes  with  its  less  fortunate  brothers.  We  have  even  been  accused 
of  attempting  to  commercialize  medicine  when  in  fact  this  is  clearly 
an  attempt  to  uncommercialize  it.  The  utmost  limits  of  commercialized 
medicine  were  reached  in  the  days,  happily  now  passing,  when  some 


— 7— 


medical  schools  with  a faculty  of  purely  part  time  teachers  were  nothing 
more  nor  less  than  feeders  for  the  consulting  rooms  of  the  faculty.  This 
is  commercialized  medicine,  if  you  please.  Our  proposition  is  precisely 
the  reverse-  The  method  suggested  for  the  conduct  of  the  University 
Hospital  has  been  criticised  on  the  ground  that  it  would  deprive  physicians 
of  their  patients  and  ruin  their  practice.  If  one  looks  carefully  at  this 
proposition,  it  at  once  appears  to  have  no  basis  in  fact.  If  half  of 
the  physicians  of  the  State  of  Michigan  were  to  send  to  the  University 

Hospital  one  patient  a year,  we  should  be  unable  to  cope  with  the 

number.  In  these  discussions,  it  has  I think  been  overlooked  that  this 
university  is  an  institution  of  the  State  and  that  it  must  be  conducted 

with  due  and  proper  regard  for  that  fact.  Beyond  question,  the  physicians 

are  entitled  to  consideration  but  so  also  are  the  sick  and  the  tax  payer. 
We  are  not  prepared  to  admit  that  the  physician  is  entitled  to  exclusive 
consideration  in  the  working  out  of  this  problem  but  we  propose  that  he 
shall  have  every  consideration  and  every  respect.  We  are  prepared 
to  consider  any  suggestion  and  any  criticism  which  is  constructive  and 
which  is  an  honest  attempt  to  aid  in  the  solution  of  the  problem.  We 
are  not  hide-bound  in  our  opinions  and  do  not  say  that  the  method 
here  adopted  is  the  only  one  or  the  best  one. 

2.  the)  teaching  oe  physicians  and  the  advancement  oe  the 

BOUNDARIES  OE  KNOWLEDGE. 

It  is  clearly  one  of  the  great  duties  of  the  Medical  School  to  be 
prepared  to  assist  physicians  not  only  in  the  management  of  any  particular 
patient  but  in  the  general  management  of  disease.  One  might  I think 
properly  regard  the  Medical  School  as  a reference  library  in  the  diagnosis 
and  treatment  of  disease.  W'e  should  be  prepared  to  put  at  the  disposal 
of  physicians  the  knowledge  here  accumulated  and  advise  them  upon 
those  methods  which  in  our  opinion  are  sound  and  those  which  are  not 
sound.  Only  in  this  way  will  the  Medical  School  discharge  its  duties 
to  the  public  and  maintain  a sound  relation  to  the  great  body  of  those 
who  must  care  for  the  sick  of  the  country. 

But  if  we  serve  no  other  purpose  than  to  teach  our  students  wisely 
and  to  present  the  problem  of  modern  medicine  skillfully  to  our  brother 
physicians,  we  should  lose  sight  of  one  of  the  great  functions  which  is 
properly  to  be  expected  of  us,  namely  research.  Research  requires  for 
its  proper  prosecution  a highly  special  environment  and  it  is  rare  ihat 
the  physician  with  a private  practice  can  at  the  same  time  carry  on 


— 8— 


far  reaching  investigations  of  medical  problems.  It  is  the  duty  of  the 
Medical  School  to  see  to  it  that  an  atmosphere  congenial  to  research 
exists  and  that  a reasonable  proportion  of  its  funds  are  at  the  disposal 
of  those  who  have  both  the  ability  and  the  desire  to  work  in  this  field. 
The  University  will  do  well  to  make  congenial  abiding  places  for  those 
with  investigative  minds  though  having  perhaps  little  or  no  capacity  to 
achieve  distinction  in  the  turmoil  of  the  world.  Such  men  allowed  to 
grow  up  under  the  proper  surroundings  may  well  contribute  more  to  the 
sum  of  human  knowledge  and  to  the  alleviation  of  human  ills  than 
many  of  their  more  practical  minded  brothers- 

3.  INSTRUCTION  OF  THE  PUBLIC  ON  QUESTIONS  PERTAINING  TO  PUBLIC 

health. 

Though  it  may  be  a somewhat  novel  conception,  it  seems  to  me 
clear  that  the  medical  school,  particularly  of  a State  University,  must 
do  its  share  in  the  work  of  disseminating  sound  opinion  on  medical 
questions.  There  is  today  a large  and  growing  group  of  agencies  part  of 
whose  function  is  the  dissemination  of  knowledge  concerning  public 
health.  With  these  agencies  and  perhaps  particularly  with  the  public 
health  officers  and  public  health  associations,  it  is  clearly  the  business  of 
the  University  through  its  medical  department  to  co-operate  to  the  fullest 
extent.  If  we  are  prepared  to  admit  that  there  can  be  no  sound  public 
health  without  as  an  antecedent  a sound  public  opinion  then  there  is  a 
great  work  for  the  university  and  one  to  which  it  must  be  prepared  to 
give  considerable  time.  In  so  far  as  it  has  officers  competent  to  speak 
with  authority  and  trained  in  the  business  of  transmitting  information  to 
the  less  informed,  these  officers  should  be  at  the  disposal  of  the  state  and 
public  health  agencies  to  assist  in  the  great  campaign  for  building  up  and 
strengthening  of  public  health. 

As  a part  of  this  function  and  one  which  at  the  moment  is  of  great 
importance  is  the  dissemination  of  knowledge  in  regard  to  the  soundest 
and  best  relationship  between  the  medical  profession  and  the  public. 
It  appears  to  be  true  that  at  the  present  time  this  subject  is  attracting 
more  attention  than  at  any  other  time,  certainly  for  many  years.  With 
the  growing  complication  of  the  field  of  medicine  have  arisen  difficulties 
in  adjustment  between  the  profession  and  the  public.  The  expense  of 
the  practice  of  medicine  to  the  physician  has  enormously  increased  and 
has  in  more  or  less  direct  ratio  increased  the  expense  to  the  patient. 
This  has  given  rise  to  much  discussion.  That  the  public  has  a real  case 


— 9— 


in  its  desire  to  obtain  medical  care  at  a reasonable  price  is  true.  But 
it  is  even  more  true  that  the  medical  profession  is  entitled  to  great 
consideration  and  should  properly  be  regarded  as  the  best  witness  con- 
cerning the  difficulties  surrounding  any  new  adjustment.  It  is  not 
necessary  here  to  go  into  the  suggested  remedies  which  have  included 
various  forms  of  compulsory  health  insurance  and  various  remedies 
classified  under  the  very  vague  phrase  of  “state  medicine.”  I desire 
only  to  point  out  that  it  is  my  opinion  that  the  State  Medical  School 
should  be  prepared  to  bear  its  part  in  this  discussion  and  I desire  to 
take  this  opportunity  of  making  clear  the  position  which  this  school 
will  take  in  the  present  discussion.  Any  proposition  for  the  amelioration 
of  real  ills  in  the  present  adjustment  which  leaves  out  of  account  or  fails 
to  give  great  importance  to  the  maintenance  of  the  present  relationship 
between  the  physician  and  the  patient  is  in  my  judgment  doomed  to 
failure  in  this  democracy.  It  is  the  essence  of  the  American  spirit  that 
it  desires  freedom  of  choice  and  though  such  choice  may  not  always  be 
wisely  made,  any  attempt  to  curtail  such  choice  will  meet  irresistible 
opposition  and  will  fail,  furthermore  it  appears  to  me  clear  that  no 
proposition  looking  to  change  can  be  successful  which  will  result  in  the 
deterioration  of  the  standing  of  the  medical  profession  in  the  community. 
The  standing  of  the  physician  in  the  community  has  always  been  a high 
one  and  he  has  been  looked  to  as  an  almost  public  official  whose  concerns 
were  less  personal  and  more  public  than  those  of  most  of  his  brethren 
Now,  any  proposition  to  change  present  conditions  which  will  importantly 
alter  this  relation,  which  will  make  the  medical  profession  one  of  lesser 
dignity  and  lesser  importance,  though  it  might  temporarily  appear  to 
remedy  the  ills,  would  in  the  end  defeat  its  own  purpose  and  have  a 
disastrous  effect  upon  the  public  health.  Unless  the  medical  profession 
be  encouraged  to  continue  in  the  future  as  in  the  past  and  unless  the 
individual  physician  continues  to  regard  himself  as  having  duties  to 
others  far  greater  than  to  himself,  advancement  in  medicine  will  be 
less  rapid,  our  ability  to  deal  with  disease  will  improve  less  certainly 
and  we  may  well  see  our  civilization  fall  because  of  the  failure  to  cope 
with  the  diseases  with  which  it  is  constantly  menaced.  I think  I may 
safely  say  that  this  faculty  will  be  found  upon  the  side  of  the  medical 
profession,  that  it  is  will  always  sympathize  with  the  demands  of  the 
public  for  improved  medical  service  but  that  it  will  cast  the  weight 
of  its  influence  in  favor  of  those  changes  which  maintain  the  dignity  of 
the  profession  and  oppose  those  which  reduce  the  profession  to  hirelings 
of  the  state,  of  the  community  or  of  the  corporation.  I take  your  time 


—10— 


to  make  these  statements  because  there  has,  I think,  been  misapprehension 
in  the  minds  of  the  physicians  of  this  state  as  to  the  views  held  by  this 
faculty.  This  misapprehension  I desire  to  correct  to  the  end  that  the 
most  cordial  relation  may  exist  between  this  faculty  and  the  medical 
profession. 


V. 


